Content Comparison

Description

Determination of whether or not the event reached the patient.

On-Screen Instructions

• ASC, Hospital, Nursing Facility: An error of omission does reach the patient.

• Pharmacy: Includes medications that make it into the patient’s possession. An error of omission does reach the patient.

Field Type

Responses

• Yes

• No

Guide for Use

If you chose more than one event type, please select the highest applicable level of harm.

Additional Support

What is a Close Call?

The Oregon Patient Safety Commission (OPSC) defines a “close call” or “near miss” as a situation that has the potential to cause an adverse event, or a situation that causes an adverse event but fails to reach the patient because of chance or because it is intercepted. Close calls include cases where there was the potential for an adverse event but no actual adverse event occurred (harm category A) or where the adverse event did not reach the patient (harm category B). OPSC encourages organizations to investigate “close calls” because they give facilities an opportunity to solve identified problems before a single patient has to experience an adverse event.

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In the interest of promoting learning, OPSC encourages reporting of close calls (harm categories A and B) and no harm events (harm categories C and D) because such events have the potential to harm a patient and, depending on the situation and patient factors, such harm could be severe. OPSC encourages participants to focus on the occurrence of an adverse event instead of the resulting harm. Focusing on the harm, rather than the system, often detracts from the real goal—preventing future recurrence and, therefore, future harm for all patients.

When does an event reach the patient?

The Patient Safety Reporting Program (PSRP) categorizes patient harm from adverse events using the widely-adopted Medication Error Index from the National Coordinating Council for Medication Error Reporting and Prevention. Categorization enables PSRP data analysis to identify trends in how and why adverse events occur.

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For example, in the scenario for harm C (above), if the nurse noticed the medication was incorrect before handing it to the patient and was able to immediately hand the patient the correct medication, then the event didn’t reach the patient (harm B). However, if getting the correct medication and giving it to the patient caused an administration delay, then the event reached the patient. Although the patient never received the incorrect medication, the event “reached the patient” because the patient’s course of care was impacted.

History